The Hippocratic Oath
and Its Challengers:
A Brief History
From: Veatch, Robert M., The Basics Of Bioethics, second ed. New Jersey: Prentice Hall, 2003.
Case 1: The Boy Who Ate the Pickle
A 9 year old youngster named Yusef Camp who lived in inner city Washington ate a pickle that he had bought from a street vendor. Soon after eating it he went into convulsions and collapsed on the sidewalk. A rescue squad took him to the nearest emergency room where his stomach was pumped. Tests revealed that the pickle contained traces of marijuana and PCP. The boy suffered severe respiratory depression and was left unconscious, unable to breathe for an unknown period.
The emergency room personnel restored respiration by putting him on a ventilator, but they were unable to restore him to consciousness or get him breathing adequately on his own.
The physicians concluded that his brain function was irreversibly destroyed and that there was no possibility of recovery. They might have simply pronounced him dead and then stopped the ventilator, but the situation soon became more complicated. Two of the attending neurologists were convinced that the patient's brain was totally dead, but one believed that he had minor brain function still in place. So they were incapable of pronouncing the patient dead based on loss of brain function. Now the question became, what should they do? Their patient was still living but permanently unconscious, breathing only because he was on a ventilator.
The physicians pointed out that there was nothing more they could do except keep the ventilator running, perhaps indefinitely and maintain the boy in a persistent or permanent vegetative state. (The longest case on record of maintaining a patient in what is called a permanent vegetative state is over thirtyseven years.) The parents were Muslims, members of the Nation of Islam, who firmly believed in the power of Allah. They believed that Allah would intervene if it was his will, and that it was the physicians' job to give Allah that opportunity. How should the physicians respond?
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In the above case the health care providers and the parents disagreed about how a permanently unconscious young boy should be treated. While the physicians felt it was appropriate to discontinue life support, the parents wanted it to continue. In fact, they could not even agree on whether the boy was dead or alive. Where might a physician, a parent, or a social observer of this scene turn for moral advice about how to handle a case like this? One possibility is to look at a code of ethics. These codes have been prepared by many different cultural, religious, and professional groups. They are lists or codifications of rules of the sort we identified in Chapter 1 as the second level of moral discourse, the next level of generality to which one might move if intuitions about specific cases resist resolution. Codes are meant to present moral rules (or perhaps rights) from the perspective of the group doing the writing. Sometimes they are limited to a specific domain such as medicine; in other codes the scope is more general.
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THE HIPPOCRATIC TRADITION
The Hippocratic Oath
For many years, some physicians have used the Hippocratic Oath as that summary of moral/medical wisdom. It is not, however, a timeless document used throughout history in all parts of the world. It is part of a collection of writings known as the Hippocratic corpus. We really don't know who wrote the oath. The fifth century B.C.E. physician known as Hippocrates (one of the original leaders of medicine on the island of Cos in ancient Greece) was almost certainly not the author (Edelstein, 1967).(1) The oath is generally believed to have been written about one hundred years later. It is one of several ethical writings along with other, more scientific ones.
Most people have not thought extensively about where the oath came from and, more importantly, about the belief system on which it was based. A provocative observation on the island of Cos should arouse curiosity. On the island are the ruins of a Greek healing temple. According to local folklore the school of Hippocrates was associated with this temple.' When local residents are asked what happened to the building, they say the destruction happened during the Christianization of Greece. Apparently, at some point in history, the Hippocratic and Christian schools of thought were sufficiently at odds that they battled to the point that the temple was destroyed. At some point in history Greek ethics and medicine were very different from ancient Christian ethics and medicine (Veatch and Mason, 1987). This raises questions that should concern moderns who see themselves standing in the Christian tradition, but affirming the oath.
The most famous twentieth century scholar of this period, Ludwig Edelstein (1967), thinks that the Hippocratic tradition arose from the Pythagorean cult (named for the same Pythagoras who gave us the Pythagorean theorem), a cult that was interested in science, philosophy, and religion, and, if Edelstein is correct, produced a school of medicine in ancient Greece known as the Hippocratic school.
If all this is true, why should a group of modern secular Western physicians caring for a Muslim patient in Washington, D.C., turn to a 2500 year old Pythagorean cultic ritual oath for moral guidance? One will begin to see that however helpful it was for an ancient medical group, for those practicing medicine today it is controversial. The oath is divided into two parts, an oath of initiation followed by a code of conduct.
The Oath of Initiation Section The oath of initiation contains a pledge of loyalty to the teacher. If the teacher should ever become short of funds, it is the student's moral duty to come to the rescue. There is also a rather strange oath of secrecy. One taking the oath pledges not to reveal the knowledge of medicine to lay people. Knowledge taught to physicians was believed to be very powerful. That power in the hands of the untrained could cause great harm. Pythagoreans also believed that knowledge should not be revealed to anyone outside the cult. We still see this attitude in modern medicine, particularly in some older physicians who are uncomfortable about sharing medical information with patients.(2) This traditional practice is at odds with our current belief that the physician has a duty to educate patients about their medical conditions and a duty to obtain consent to treat that requires that the patient be informed.
The oath section also contains a pledge to the Greek gods and goddesses Apollo, Aesclepius, Hygia, and Panacea. Modern physicians have felt it necessary to modify that sentence. They might substitute authorities within their own religious tradition or even secular authorities.
By contrast other religious traditions such as Judaism and Christianity, base their ethics on a covenant relationship between Yahweh and his people. They do not include a vow of secrecy. The Judeo-Christian belief, especially in Protestantism, is that all are capable of using knowledge responsibly.
Education is also important in secular liberal political philosophy. Liberal political philosophy has its origins in the philosophy of Locke, Hobbes, and Rousseau and reaches its best known political expression in the documents of the American founding fathers. It stresses the importance of the individual and commands respect for individual liberty even if other people believe they know what is best. It also incorporates a belief in the equality of moral worth of all persons, providing a basis for various concerns about social justice. Its proponents believe that people have a right to know; the development of an informed consent doctrine illustrates the pervasiveness of this conviction. None of this discussion of patients' rights appears in any of the Hippocratic writings. We begin to see that the Judeo-Christian attitude and that of secular liberalism, as well as other traditions, have medical ethical doctrines that differ from this old Pythagorean Hippocratic tradition.
The Code Section of the Oath The second half of the oath contains the code of ethics itself. It is divided into three parts, dealing with dietetics, pharmacology, and surgery.(3) The third section contains an odd prohibition that requires physicians to swear that they will never practice surgery. Translations differ a bit, but the best translation prohibits "even on sufferers from stone," which presumably refers to bladder stone surgery. Because that was relatively simple surgery even in ancient times, this statement seems to emphasize that the prohibition is categorical and not merely reflecting an awareness that surgery in ancient times was too dangerous.
Why would a medical ethical oath forbid its physicians to practice surgery? One explanation is that the original meaning was that the Hippocratic physician should not practice surgery because surgery involves contamination, i.e., touching blood and waste products, which is religiously defiling. Pythagoreans worried about such ritual contaminations. The oath does not say that surgery is inherently dangerous, but rather that Hippocratic physicians should leave surgery to persons who practiced that particular branch of medicine. In short, there is a moral division of labor like that seen in some traditional cultures, in which those in priestly roles were kept "pure." This interpretation is supported by the fact that the oath holds out "purity and holiness" as the two key Hippocratic virtues.
The oath also contains other prohibitions. The Hippocratic physician will not give deadly drugs. Euthanasia is prohibited, as are abortifacients.(4) Most important, the oath contains what can be called its core principle, namely, that the physician should benefit the patient according to his ability and judgment.(5) Decisions are made as to what should benefit the patient, based on the physician's ability and judgment, not the patient's. Hence, the Hippocratic ethic is often considered paternalistic, that is, it approves of actions intended to benefit another person even if that person does not want the benefit. Often in medicine this paternalism arises because the health professional is focusing exclusively on medical benefits of treatments while the patient may be willing to sacrifice these medical benefits in order to obtain nonmedical benefits considered more important or desirable. (Smoking, consuming unhealthy foods, and failing to exercise are all possible examples.)
By contrast, other ethics are of a different style. Some interpretations of Judeo-Christianity, for example, see it as less paternalistic and differ from the Hippocratic Oath in other significant ways. The other major religious and secular traditions of the world Hinduism, Buddhism, various Chinese traditions, Marxist thought, and, for our purposes probably the most significant, to liberal political philosophy of the modern West all have something that can be considered an ethic for medicine. All of these will be seen as contrasting to the Hippocratic tradition that has been so prominent in the medical ethics at various times over the past 2500 years. Hence, if physicians or parents or anyone else is seeking moral guidance for a case such as that of Yusef Camp, they will need to determine on which of the many ethical systems that are available they wish to rely.
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Modern Codes in the Hippocratic Tradition
Percival's Code of 1803 Several modern professional ethical codes stand in the Hippocratic tradition, at least in the sense that they stress the duty of the physician to benefit the patient. By far the most important for the English speaking world is the code of Percival, published in 1803 (Percival, 1985 [1803]). The need for a written ethics code for medicine arose from a typhoid and typhus epidemic in Manchester, England, that occurred in the 1790s. As a result the Manchester infirmary staff were overworked. Medicine in the eighteenth century in Britain was divided very much the way it was in the Hippocratic tradition. There were physicians who specialized in dietetics, surgeons, and apothecaries, who worked with drugs. With the pressure of this epidemic, it was more than they could handle. They began to fight among themselves about who should be doing what.
A physician named Thomas Percival had quit practicing medicine around this time because of a physical disability. He was well educated, and everybody thought well of him. The physicians embroiled in the dispute asked him to mediate the dispute. The result was a volume of ethical guidance. Thus the purpose of the code was originally to mediate quarrels among physicians, not to deal with relationships with patients. Percival's code was published in revised form in 1803. It was in the Hippocratic tradition in that it stressed the duty of the physician to benefit the patient and placed no emphasis on the rights of patients in matters such as informed consent or open disclosures.(6)
This duty to benefit the patient combined with the absence of any recognition of the rights of patients, is the hallmark of the Hippocratic tradition. It is one of the major differences between medical ethics that is Hippocratic and many of the other religious and secular ethics we shall be considering. The focus on benefit to the patient has become the foundation not only of British, but American professionally sponsored medical ethics as well.
The AMA Code of 1847 In the United States at the beginning of the nineteenth century, a number of schools of medical thought existed side by side, just as in ancient Greece. Members of these schools began to fight among themselves, each wanting to establish theirs as the dominant school. In 1847, one group, representing what we now call allopathic (or orthodox and scientific) medicine, founded the American Medical Association to accomplish this end and to combat what they thought of as quackery.
They recognized that if theirs was going to be a profession, as opposed to a mere business, they had to have a code of ethics. (Sociologists of the professions note that writing a code of ethics is often a distinguishing mark of a profession.) In writing one, they turned to Percival's Code, taking whole sections of it and incorporating them into their original 1847 Code of Ethics of the AMA (AMA, 1848). So both Britain and the United States had codes of ethics that are essentially Hippocratic in their content, focusing on benefit to the patient. However, they both also discussed the duties of physicians to benefit society, something the Hippocratic ethic never mentioned.
The World Medical Association Declaration of Geneva, 1948 Just after the Second World War, the World Medical Association, a conglomeration of national medical societies, needed a code to respond to the medical experiments in the Nazi concentration camps. In 1948 this group developed the Declaration of Geneva (World Medical Association, 1956). Its contents are remarkably similar to the Hippocratic Oath. Deleting from the old oath the references to Hygiea and Panacea and all the old gods and goddesses and the prohibition on surgery and abortifacients, it still includes the key sentence that is a slightly modified version of the Hippocratic Principle. It now reads "the health of my patient will be my first consideration." Essentially, then, a Hippocratic Oath in modem language governs this organization of world medical associations. The World Medical Association is no more cognizant than the Hippocratic Oath of the problem that arises when the patient does not want her health maximized, that is, when she has something else on her agenda other than health, or when she disagrees with the physician about what would count as improving her health.
Other Contemporary Oaths or Codes in the Hippocratic
Tradition Just under half the medical schools in the United States and Canada (47 percent) still administer some version of the Hippocratic Oath to their graduates, but only one school (State University of New York at Syracuse) was reported in a 1997 article still to use the original version (Orr, Pang, Pellegrino, and Siegler, 1997). Similar patterns appear in other countries with some schools using the Hippocratic form, usually modified, and others using an oath of entirely different origin.
In post Soviet Russia, physicians have recently constructed an oath for the Russian physician. ("Solemn Oath of a Physician of Russia," 1993). Wanting to replace the Soviet oath with its significant Marxist influences, Russian physicians took the old Hippocratic Oath and translated it into Russian, cleaning it up in a manner similar to that of the World Medical Association. Another example is the Academic Oath of St. George's University School of Medicine in Grenada. It also uses a rewrite of the Hippocratic Oath. Its version, however, requires the graduating medical student to work for the benefit of the patient rather than merely the patient's health. The key sentence reads, "The regimen I prescribe will be for the good of my patients, according to my ability and judgment." We shall see in Chapter 4 that there can be a difference between working for the patient's total welfare and focusing more narrowly only on the patient's health.
There are other rewritings, such as the Florence Nightingale Pledge for nurses. It wasn't written by Florence Nightingale any more than the Hippocratic Oath was written by Hippocrates, but it is a thinly modified rewriting of Hippocrates' oath ("Editorial Comment," 1911).
Until the later decades of the twentieth century, then, physicians often used some version of the Hippocratic Oath as their ethical code (and some continue to do so to this day). The definitive feature is a commitment of the physician to benefiting the patient without any acknowledgment of patients' rights, such as the right to be told the truth or to give consent before being treated. The more purely Hippocratic codes also pay no attention to the welfare of society or other individuals (although we have seen that both Percival and the AMA depart slightly from the standard Hippocratic formula by secondarily mentioning some concern for social benefits).
But beginning about 1970, the Hippocratic tradition started to collapse. Observing this collapse is in a way quite exciting; it must be like being with Galileo during the revolution in astronomy or with Albert Einstein when atomic physics was emerging. A new medical ethics emerged on the horizon, particularly for Western culture that has its roots in ancient Judeo-Christianity, but more explicitly in secular liberal political philosophy.
THE COLLAPSE OF THE HIPPOCRATIC TRADITION
The Hippocratic Oath is being challenged in three ways. One preliminary challenge deals with the way in which benefits are assessed. The oath makes an enormous presumption when it says that a physician should judge what is best for his or her patient according to the physician's ability and Judgment as in some cases, the physician's colleagues who are competent in their field may not concur. Even if they do, the patient may prefer some other course. In this sense the oath's assessment of benefit is subjective. In Chapter 4 we shall discuss further the problems with the subjective notion that it is the physician's standard of benefit that is decisive.
A second challenge involves problems that arise when benefits conflict with other kinds of moral duties, particularly those related to rights of patients and obligations owed to them. Many ethical theories hold that there is more to ethics than merely producing good consequences. They affirm moral obligations and rights that are relevant to deciding what is ethically right conduct regardless of the consequences. In Chapter 5 we shall talk about conflicts between benefiting the patient and respecting certain rights of the patient, including the right to the truth, the right to have one's autonomy respected, and the right to have promises kept. Then in Chapters 6 and 7 we shall talk about the rights of the dying.
The third challenge to the Hippocratic tradition arises when there is a conflict between the interests of the patient and those of others. The oath, at least in its original form, focuses exclusively on the individual patient. In Chapter 8 we will look at the way in which this focus on the individual conflicts with the health professional's duty to others in the society in the areas of research medicine, public health, or cost containment.
Codes and Oaths Breaking with the Hippocratic Tradition
The Nuremberg Code, 1946 Several kinds of medical codes or oaths break with this Hippocratic tradition. The first and most dramatic challenge in modem times came shortly after World War II with the Nuremberg trials. People began to question Nazi physicians about the painful, sometimes lethal, studies they had been doing on unwilling concentration camp prisoners. It became obvious that research on humans could be ethically controversial. The agenda being pursued in these studies was set by the Nazi state. The experiments were not for the benefit of prisoners in concentration camps. It is the very nature of medical research (as opposed to innovative therapy) that the goal is to produce knowledge, not to benefit the subject. On the other hand, the Hippocratic ethic requires that physicians act solely for the individual patient's benefit.
The Nazi physicians had abandoned the traditional ethical commitment of the physician to the individual patient's welfare. The Nuremberg trials uncovered a serious problem, Nazi physicians were not working for the benefit of their patients. One option would be to go back to the Hippocratic formula, requiring that physicians focus only on individual patient welfare, but that would mean they could never do any more research for the purpose of promoting the good of society. While the Hippocratic ethic would have prohibited the Nazi experiments, it would also have foreclosed even the most benign and defensible research.
Instead of returning to a Hippocratic model, spokespersons for Western society acknowledged that research was necessary for the benefit of humankind, but they also realized that some protection was needed for the individual patient. This protection came in the form of requiring consent from subjects so they could look out for their own interests. The resulting Nuremberg Code ("Nuremberg Code," 1946) was the first medical ethical document in the 2500 years after Hippocrates that mentioned the concept of informed consent, that is, the notion that the patient or subject has the right to be informed of the relevant facts of what is being proposed and to approve or disapprove before the physician proceeds.
A second important difference exists between The Nuremberg Code and the codes in the Hippocratic form. The Nuremberg Code is a public document of international law, not one written by the medical profession and bestowed on the public. We are beginning to see the clash of two different perspectives that represent two radically different ethical traditions. The result was an explosion beginning in about 1970, and it was dramatic. One strand, represented by the Nuremberg Code, is grounded in liberal political philosophy. The other, from the Hippocratic tradition, shows no such influence. This Hippocratic tradition is older, more paternalistic, and, as we are beginning to discover, is incompatible with the liberalism on which the Nuremberg Code is based, at least in certain areas like research medicine.
The American Hospital Association Patient Bill of Rights, 1973 Another document breaking with the Hippocratic view came from the American Hospital Association in 1973, right at the beginning of the full blown clash between the Hippocratic and liberal traditions. The American Hospital Association's Patient Bill of Rights, goes a long way toward focusing on the rights of patients. It includes informed consent and a right to information. Nothing like that ever appeared in the Hippocratic tradition. Notice, though, that this affirmation of patient rights is coming not from the Medical Association but the Hospital Association.
American Medical Association Principles of 1980 It was not until 1980 that the AMA changed its code in a dramatic, significant way. The new version, adopted that year and published in 1981, finally begins speaking of the rights of patients. The use of the word rights is a signal that something new is going on. A right is a claim to a moral or legal entitlement. Those rights cannot be defeated merely by appeals to good consequences that would result from failing to honor them. The Hippocratic Oath never mentions anyone's rights. The language of rights is, after all, a modern notion grounded in the liberal political philosophy.
Other National Medical Associations Other national medical association are now abandoning their more traditional Hippocratic codes in favor of revised documents that more explicitly affirm consent, confidentiality, and other rights of patients. For example, the Federal Council of Medicine, Brazil adopted a new code in 1988. The New Zealand Medical Association did so the following year.
Sources from Outside Professional Medicine
We also begin to see the emergence of medical ethical documents from other sources to which physicians, parents, or others confronting difficult decisions such as that involving Yusef Camp might turn.
Judaism, Catholicism, and Protestantism Just as international law has provided a source for a code coming from outside the medical profession, religious traditions also have medical ethics. They are seen in Talmudic Judaism (Rosner and Bleich, 1979) and Catholic moral theology (National Conference of Catholic Bishops, 2001). Protestant ethics has positions on many medical ethical issues including abortion, euthanasia, and the right of access to medical care that come from moral sources fundamentally different from those of organized medicine.
Hinduism Outside of the West, many ancient religious traditions have developed medical ethical positions as well. The Hindu Vedic scriptures, for instance, contain a medical ethic. The Vedic texts are classical religious writings. One branch of those writings, the Ayur Veda, contains medical material including a code of ethics called the Caraka Samhita ("Oath of Initiation [Caraka Samhita]," 1978). This code required that the physician not injure or abandon the patient and not cause his death. One of the provisions in that document that makes very little sense to Westerners, but is understood within the Vedic tradition, is a pledge of the physician that he will not treat those who are haters of the king. There is nothing like this provision in Western medical ethics, but it is perhaps more understandable against the backdrop of the religious traditions of ancient India.
Buddhism The classical Buddhist ethic involves an eightfold path that incorporates five precepts. These precepts include prohibitions on killing, lying, and drinking intoxicants, revealing that the Buddhist tradition has definite implications for the practice of medicine.
Ancient Chinese Thought Ancient China developed a complex, rich culture that included the thought of Confucianism as well as strands of Buddhist and Taoist thinking. By the seventh century, c.e., Chinese writing began to focus explicitly on medicine. Sun Simiao included a famous treatise "On the Absolute Sincerity of Great Physicians" in his work The Important Prescriptions Worth a Thousand Pieces of Gold. Widely believed to reflect Buddhist and Taoist influences, it affirms special moral duties for professional physicians.
Islam There are a number of Muslim oaths or codes for physicians. The Islamic Code of Medical Ethics was prepared in Kuwait in an international meeting of Islamic scholars in 1981 (International Organization of Islamic Medicine, 1981). Islamic medicine has a strong prohibition on killing, including mercy killing and abortion. There is an affirmation of Allah's will, the notion that we saw in the case of Yusef Camp.
Japan Japanese ethics also has rich traditions relevant to medical ethics. Consider the following case:
Case 2: Physician Assistance in a Merciful Homicide
A young woman had just given birth, in Tokyo. She was unmarried, had no close relatives who could help her raise this child, and had a malignancy of the breast. In fact, it had now metastasized. The oncologist told her she probably only had a few more months to live. The woman said to the oncologist, "I want you to help me to do the most loving thing that I can do for my child. I would like you to tell me how I can mercifully kill my child so that when I die, the child will not be condemned to the life of an orphan."
The physician pointed out that there were other possibilities. For instance, someone could adopt the child. The mother understood this. She said, "My child is a girl. My child has a deformed hip. That close bond between mother and child is destroyed forever with my death. So my child will never be able to do well."
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There is a concept in Japanese culture called amae, which is roughly translated as dependency, a close bond between a mother and child that would be irretrievably destroyed with the mother's death (Doi, 1981). There is also in Japanese culture a concept called joshi. Joshi can be translated as "love killing," or mercy killing. It is sometimes carried out by the head of a household who is disgraced in business. He might, as a merciful act, kill not only himself, but also mercifully take the lives of his wife and children so they would not be disgraced. Though illegal today, this practice, which comes out of the more traditional edo period in Japan, still occurs. This woman's request reflected these old beliefs. Japanese people today understand the concept, and it doesn't surprise them that a mother could ask for help from her physician not only to kill herself, but to kill her infant child. The striking thing about this story is that the physician understood. Most physicians, even in Japan, would not have cooperated but they well might understand. It is impossible to understand that story without knowing a great deal about traditional Shinto doctrine and beliefs. It is the exception rather than the rule, but it does happen.
The Oath of the Soviet Physician All of these traditions in medical ethics leave us with the realization that those facing a choice in Yusef Camp's case and in similar situations cannot assume that the Hippocratic ethic and the professional consensus about what is ethical are automatically correct. There are many different traditions specifying what is ethical in medicine. These are not limited to the religious traditions. In secular philosophy a number of schools of thought have implications for medical ethics that differ from the Hippocratic tradition. One example is the Soviet Oath from 1971 ("Oath of Soviet Physicians," 1971). It contains, among other things, a pledge of loyalty to the Communist society. Other political philosophies have implications for medicine as well.
Liberal Political Philosophy One of these is seen in the most important intellectual movement in modem Western culture, the tradition of liberal political philosophy. It is the dominant philosophical orientation of secular society in the United States and most other nations of the West. Liberalism emerged as the major challenger of the more paternalistic Hippocratic tradition in the last quarter of the twentieth century Patients' bills of rights are emerging that reflect liberal political philosophy such as the Council of Europe Convention on Human Rights and Biomedicine (1997) and United States Consumers' Bill of Rights of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1997).
After exploring the question of who it is who has full moral standing in the next chapter, in Chapter 4 we will begin an analysis of the Hippocratic approach to medical ethics. We will ask what moral problems arise if we assume that the goal of medicine is to produce benefits for the patient and to protect the patient from harm.
KEY CONCEPTS
Hippocratic Oath: The code of physician ethics attributed to the Greek physician, but more likely written by his followers in the fourth century B.C.E. Often believed to be related to a Pythagorean cultic belief system.
Hippocratic Principle: The core principle of the Hippocratic Oath, holding that the physician pledges to benefit his patient according to his ability and judgment and protect the patient from harm; cf. Social Consequentialist Ethics, Deontological Ethics, in Chapter 4.
Liberal Political Philosophy: The dominant commitment of secular society in the United States and most other nations of the West that has its origins in the philosophy of Locke, Hobbes, and Rousseau and reaches its most well known political expression in the documents of the founding fathers of the American political system. It stresses the place of the individual and commands respect for the liberty of the individual. It also incorporates a belief in the equality of moral worth of all persons, providing a basis for various concerns about social justice.
Rights: Justified moral or legal claims to entitlements or liberties often seen as taking precedence over ("trumping") considerations of consequences. Rights normally stand in a reciprocal relation with moral or legal rules, i.e., if someone has a rights claim against some other party, that other party is duty bound by a rule requiring that the right be respected.
Hippocratic Codes or Oaths
Closely Reflecting the Hippocratic Tradition:
The Hippocratic Oath
The Hippocratic Oath Insofar as a Christian May Swear It
The Florence Nightingale Pledge
The Declaration of Geneva State University of New York at Syracuse
The St. George's University Academic Oath
The Oath of The Russian Physician
Qualified Hippocratic Content:
Percival's Code of 1803
The AMA Principles of 1847
NonHippocratic Codes and Oaths
Professionally Generated Codes Significantly Departing from the Hippocratic Tradition:
The AMA Principles of 1980
American Nurses' Association. Code for Nurses with Interpretive Statements, 1985
The Chilean Medical Association (1983)
The American Nurses Association Code for Nurses (1985)
The Federal Council of Medicine, Brazil (1988)
The New Zealand Medical Association (1989)
Medical Ethical Systems Based on Nonprofessional Ethical Traditions
Ten Maxims for Physicians and Ten Maxims for Patients, China
The Ethical and Religious Directives for Catholic Health Facilities
The Caraka Samhita of the Hindu Ayur Veda The Seventeen Rules of Enjuin, Japan, Seventeenth Century
The Islamic Code of Medical Ethics
The Oath of Maimonides (Jewish)
The Oath of Soviet Physicians (1971)
The AHA Patients' Bill of Rights
Council of Europe Convention on Human Rights and Biomedicine (1997)
The Consumers' Bill of Rights of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1997)
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ENDNOTES
1. In fact, there is reason to believe that Hippocrates was not a part of this temple, but rather a challenger to the earlier religious healing system.
2. Likewise, until recently, pharmacists were taught that a pharmacist was not to put the name of the prescription medication on the label and should not tell the patient the name of the drug, because somehow that was information that could harm patients. They might hear that that drug was used for other diseases and become distressed with the thought that they might have such a condition. Or they might read about side effects and become unnecessarily alarmed about them.
3. One of the reasons we are convinced that the oath is Pythagorean in origin is because that is exactly the way the Pythagoreans divided the world of medicine, even though most other Greek schools of thought did not.
4. Some people say that the Hippocratic prohibition on abortion dovetails with Christian objections to abortion, (Edelstein 1967, pp. 6263; Carrick, 1985, p 159; Temkin, 1991, p 182) and that is why the two traditions came together. But if one looks at the ancient tradition of Christianity, one will see that in all the documents that exist from the first eight centuries of Christianity only eleven references are made to the Hippocratic writings (Veatch and Mason, 1987). Nine of those eleven had nothing to do with the Oath. They praise the quality of the writings holding it as a model of classical Greek writing style. Only two references mention the Hippocratic Oath in eight centuries of the Christian era. Both were rather hostile to Hippocratic concepts, reflecting a difference between the Christian and Hippocratic traditions.
5. In Hippocratic medicine, physicians were always male.
6. Classifying Percival's work as in the Hippocratic tradition is now the standard reading of his ethics. That is the position taken by Leake (Percival, 1927; Waddington, 1975 & 1984 and Berlant, 1975). More recent scholarship is now questioning this reading of Percival. At least, while the Hippocratic Oath focuses on the individual, isolated patient physician relation, Percival differs by including extensive discussion of social relations including the duty of the physician to society. It is also now becoming clear that Percival was much more conversant with the contemporary philosophical literature of the time and not just repeating Hippocratic formulas (Baker, 1995).
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